Involved-field radiotherapy and intra-Ommaya methotrexate/cytarabine in patients with AIDS-related lymphomatous meningitis.

PURPOSE: To evaluate combined limited-field radiotherapy and concentration times time (C X T) intra-CSF chemotherapy in patients with AIDS-related lymphomatous meningitis (LM). PATIENTS AND METHODS: Fourteen men and one woman with AIDS had cytologically documented LM. Eleven patients had systemic non-Hodgkin's lymphoma (NHL) (all B-cell histology, including six immunoblastic, four large cell, one small cell) with leptomeningeal metastases and four patients had primary CNS lymphoma (PCNSL) (all B-cell histology, including two immunoblastic, two large cell) with CSF dissemination. Presenting neurologic examinations included cranial neuropathies (n = 7), normal (n = 4), abulia (n = 2), paraparesis (n = 2), ataxia (n = 1), hemiparesis (n = 1), and aphasia (n = 1). Standardized pretreatment evaluations included contrast cranial magnetic resonance/computed tomography (MR/CT), placement of an intraventricular reservoir, CT myelogram/contrast spine MR, ophthalmologic examination, and indium 111-pentetic acid (DTPA) CSF flow studies. Regions of bulky or symptomatic disease were treated with limited-field radiation therapy, which included whole brain in 10 patients combined with spinal cord irradiation in five patients. Concurrent systemic chemotherapy was administered in 12 patients. All patients were scheduled to receive intraventricular methotrexate (MTX) 2 mg/d for 5 consecutive days biweekly for 8 weeks (induction), followed in cytologically responding patients by MTX administered in a similar manner every 4 weeks (maintenance). In MTX-responsive and consenting patients with cytologic relapse, intraventricular cytarabine (ara-C) was administered, 25 mg/d for 3 consecutive days weekly for 4 weeks (induction), followed by ara-C administered in a similar manner every 4 weeks (maintenance). CSF cytology and neurologic examinations were performed biweekly. RESULTS: In 13 assessable patients (two patients refused CNS directed therapy following standardized pretreatment evaluations), median time to tumor progression was 60 days (range, 3 to 260) and median survival duration was 125 days (range, 44 to 260). Response rate, determined clinically (four of 13 patients) and cytologically (nine of 13), was 69%. Complications included reservoir infection (n = 2) and myelosuppression (n = 11); the latter was felt to be a consequence of coadministered systemic chemotherapy. CONCLUSION: There were no treatment-related deaths. We conclude that involved-field irradiation and intraventricular MTX/ara-C is effective palliative treatment of AIDS-related LM.

Amaurosis fugax due to pituitary tumor.

Amaurosis fugax in a younger person in whom premature atherosclerotic disease and cardiac emboli have been eliminated is usually benign. We describe a 25-year-old man with recurrent painless left monocular visual loss lasting from 5 to 45 minutes. Initial physical examination, carotid ultrasound, and electrocardiogram were normal. Goldmann visual field testing demonstrated a small, left paracentral defect. Neuroimaging studies were initially declined for economic reasons, but later a magnetic resonance image disclosed a large pituitary tumor displacing the left optic nerve and chiasm. The tumor was removed via a transphenoidal approach, and the episodic visual symptoms disappeared. We stress that amaurosis fugax in young patients is not necessarily benign. A specific etiology should be diligently sought, particularly when ocular signs are present.

A false-positive edrophonium test in a patient with a brainstem glioma.

We report a photographically documented false-positive edrophonium test in a patient with a histologically verified brainstem glioma. While a positive response to intravenous edrophonium should usually be regarded as confirmatory for myasthenia gravis, the possibility of a false-positive test must be considered in patients with atypical physical findings.

[Dysfunction of the esophageal groove ("ruminal drinking") as a complication of neonatal diarrhea in the calf]. / Dysfunktion der Schlundrinne ("Pansentrinken") als Komplikation der Neugeborenendiarrhö beim Kalb.

It is well documented that the induction of the oesophageal groove reflex in the milk fed calf depends on certain prerequisites: The fluid drunk by the calf must come into contact with the receptors located in the pharynx, it must be consumed voluntarily by the animal without undue disturbances, it should have no offensive smell or taste and the general status of the calf should not be disturbed. When those conditions are not met the oesophageal groove closes incompletely or not at all and the milk flows into the reticulo-rumen. If the milk or any other nutrient solution remains there for a sufficient period of time, the nutrients it contains are subjected to bacterial breakdown. In a study including 249 calves (age less than 14 days) suffering from enteritis catarrhalis acuta it could be demonstrated that no closure of the oesophageal groove occurred in 11.2% of the patients; 11 calves of that group died. The same was probably true for a further 11.8% of the diarrheic calves; 12 of them died. In 37 ruminal drinkers, suffering from neonatal diarrhea (n = 30) or another primary disease (n = 7) the acid status of the rumen fluid could be examined several times. According to the analyses the following types of fermentation could be distinguished: --predominant butyric acid fermentation; --predominant lactic acid fermentation; --"biphasic type": predominant lactic acid fermentation changes to predominant butyric acid fermentation or vice versa. In the milk fed calf suffering from neonatal diarrhea, dysfunction of the oesophageal groove reflex (ruminal drinking) with its consequences (rumen acidosis, dyskeratosis of the ruminal mucosa) can result in a fatal outcome.